Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

Reducing Interruptions – How To Send The Wrong Message

The less time off the chest, the better the results for the victim of out-of-hospital cardiac arrest. Educating EMS providers in performing high-quality CPR possible is crucial. (Photo Ryche Guerrero)[1]

JEMS has a good article, and it is on an important topic, but whoever decided to use the picture (above) that accompanies the article needs to cut back on the use of the crack pipe, just a little bit, or maybe just cut back while at work.

The article is about the importance of quality in the performance of chest compressions, but the picture seems to have been staged to demonstrate as many errors as possible. Maybe this is not at all representative of what this crew normally does, but somebody should have looked at it, giggled let out a heavy sigh of despair, and looked for something that does not contradict the message of the article.

Is this a trauma code? The immobilization may be a part of the movement by some in EMS to have us put collars on intubated patients, rather than have us pay attention to the way we move patients. If the goal is to just prevent the tube from being dislodged, we should not tape the head down as, well. The collar does not make a dislodged tube impossible, so if the tube is dislodged, now (depending on the amount and type of tape used) we might wish we hadn’t applied tape.

So I will assume that this is a trauma code, which raises the question – What century are we in? Why are we doing compressions on a trauma code? Why are we transporting a trauma code?

We have four people and a dead body. Each is in his/her own little world, doing his/her own little thing.

Someone behind the door is bagging the patient through the endotracheal tube, because this is about how much more important compressions are than ventilations.

Monitor Guy is doing something monitorish, because otherwise there might not be anything to do – except relieve the guy attempting compressions.

Headset Guy appears to be pushing drugs, because drugs have not been shown to improve outcomes in cardiac arrest.

Headset? Why do we have headsets? Well, it appears that the fashionable attire of Monitor Guy and Headset Guy includes some dandy little flight patches. So, not only does this appear to be an inappropriate transport of a dead guy, but it appears to be an inappropriate flight of a dead guy. On the plus side, the flight is not for mechanism only. Lemonade anyone?

Maybe the flight crew was called for the patient while the patient was still alive and they are only assisting the ambulance crew to the ambulance with the patient. Nobody flies dead people, at least not in this century. Right? Or should this flight service be known as Corpse Flight – nobody is too dead for low altitude at high prices!

One guy left. The guy who is actually doing compressions. Maybe I shouldn’t use the words actually, or doing, since at the angle demonstrated, Arnold Schwarzenegger would have trouble generating effective compressions.

But we don’t have a better way of performing compressions while loading the patient in the ambulance, for the ride to the landing zone, for the flight to the helipad, for the elevator ride(s) (or is it another ambulance ride) to the ED, where someone may feel the need to continue the code for a little while, just to avoid hurting the feelings of everyone who has worked so hard to get him here.

This is resuscitation theater, not medicine.

This is not about the patient, but about putting on a show – and in this case it does not even appear to be a good show.

Why are we endangering all of these people, just to put on a show? Ground crews deserve better. Flight crews deserve better.

Compressions are important. Interruptions in compressions lead to worse outcomes.

it’s clear that educating EMS providers in performing the best quality CPR possible and monitoring those efforts to ensure that these skills are not deteriorating over time is also a crucial component that EMS systems need to direct time and resources to in order to increase OOHCA saves.[1]

The article was also selected by JEMS as one of its Best of JEMS series, where they chose what they believe to be their best article of the year. This is their choice for 2010 – as of the Ides of March, 2010. Late addition – 7-15-10 19:48

Trackbacks

[…] Heightman and I may disagree on many things, but I do not doubt his integrity. I wrote Reducing Interruptions – How To Send The Wrong Message back in January. This was also about a photograph providing the wrong initial impression. A.J. […]

Ignorance is preferable to error; and he is less remote from the truth who believes nothing, than he who believes what is wrong.

- Thomas Jefferson

Notes on the State of Virginia (1781-1783)

-

Bigotry and science can have no communication with each other, for science begins where bigotry and absolute certainty end. The scientist believes in proof without certainty, the bigot in certainty without proof. Let us never forget that tyranny most often springs from a fanatical faith in the absoluteness of one’s beliefs.

Ashley Montagu.

-

Today we rely less on superstition and tradition than people did in the past, not because we are more rational, but because our understanding of risk enables us to make decisions in a rational mode.

- Peter L. Bernstein

Against the Gods: the remarkable story of risk (1996)

-

Mark my word, if and when these preachers get control of the [Republican] party, and they're sure trying to do so, it's going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can't and won't compromise. I know, I've tried to deal with them.

Barry Goldwater.

-

I think every good Christian ought to kick Falwell right in the ass.

Barry Goldwater

Said in July 1981 in response to Moral Majority founder Jerry Falwell's opposition to the nomination of Sandra Day O'Connor to the Supreme Court, of which Falwell had said, "Every good Christian should be concerned." as quoted in Ed Magnuson, "The Brethren's First Sister," Time Magazine, (20 July, 1981)

-

What do you think science is? There's nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?

Dr. Steven Novella.

-

What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books.

Sigmund Freud (1933)

Today the samizdat is digital and burning a copy has the opposite meaning. A little later, persecution of the Jews was once again the law - Freud's four sisters all died in concentration camps, although not by burning.

-

"Can you prove that it’s impossible?” “No”, I said, “I can’t prove it’s impossible. It’s just very unlikely”. At that he said, “You are very unscientific. If you can’t prove it impossible then how can you say that it’s unlikely?” But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible. To define what I mean, I might have said to him, "Listen, I mean that from my knowledge of the world that I see around me, I think that it is much more likely that the reports of flying saucers are the results of the known irrational characteristics of terrestrial intelligence than of the unknown rational efforts of extra-terrestrial intelligence." It is just more likely. That is all.

Richard Feynman.

The Character of Physical Law (1965)
chapter 7, “Seeking New Laws,” p. 165-166:

It has been over half century since Feynman explained this. The reports of flying saucers have continued, but there is still no valid evidence to support belief in flying saucers. Feynman's explanation is a good definition of unlikely.

-

An ignorant mind is precisely not a spotless, empty vessel, but one that’s filled with the clutter of irrelevant or misleading life experiences, theories, facts, intuitions, strategies, algorithms, heuristics, metaphors, and hunches that regrettably have the look and feel of useful and accurate knowledge.

David Dunning - explaining the Dunning-Kruger effect.

-

Treat beliefs not as sacred possessions to be guarded but rather as testable hypotheses to be discarded when the evidence mounts against them.

Philip Tetlock.

-

Squatting in between those on the side of reason and evidence and those worshipping superstition and myth is not a better place. It just means you’re halfway to crazy town.

PZ Myers

-

The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

-

Imagine a world in which we are all enlightened by objective truths rather than offended by them.

Neil deGrasse Tyson

-

Education is a progressive discovery of our own ignorance.

Will Durant.

-

You don't use science to show that you're right,

you use science to become right.

Randall Munroe

-

Just because science doesn't know everything doesn't mean you can fill in the gaps with whatever fairy tale most appeals to you.

There appears to be in mankind an unacceptable prejudice in favor of ancient customs and habitudes which allows practices to continue long after the circumstances, which formerly made them useful, cease to exist

Benjamin Franklin.

-

If science proves some belief of Buddhism wrong,

then Buddhism will have to change.

Tenzin Gyatso, 14th Dalai Lama.

-

Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them;

Thomas Jefferson.

-

Science doesn't make it impossible to believe in God.

It just makes it possible to not believe in God.

Stephen Weinberg.

-

There are no forbidden questions in science,

no matters too sensitive or delicate to be probed,

no sacred truths.

Carl Sagan.

-

The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

-

It is better to not understand something true,
than to understand something false.

Neils Bohr.

-

God does not play dice with the universe.

Albert Einstein

Stop telling God what to do with his dice.

response by Neils Bohr.

-

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

Paracelsus.

-

What is not true, as everyone knows, is always immensely more fascinating and satisfying to the vast majority of men than what is true.

H.L. Mencken.

-

Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are.

Niels Bohr.

-

How wonderful that we have met with a paradox. Now we have some hope of making progress.

Niels Bohr.

-

An expert is a man who has made all the mistakes which can be made in a very narrow field.

Niels Bohr.

-

Every sentence I utter must be understood not as an affirmation, but as a question.

Niels Bohr.

-

Some subjects are so serious that one can only joke about them.

Niels Bohr.

-

I have no special talents. I am only passionately curious.

Albert Einstein.

-

Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions.

Albert Einstein.

-

Never memorize what you can look up in books.

Albert Einstein.

-

The prestige of government has undoubtedly been lowered considerably by the prohibition law. For nothing is more destructive of respect for the government and the law of the land than passing laws which cannot be enforced. It is an open secret that the dangerous increase of crime in the United States is closely connected with this.

Albert Einstein.

-

the chance is high that the truth lies in the fashionable direction. But, on the off-chance that it is in another direction - a direction obvious from an unfashionable view of field theory - who will find it? Only someone who has sacrificed himself by teaching himself quantum electrodynamics from a peculiar and unusual point of view; one that he may have to invent for himself. I say sacrificed himself because he most likely will get nothing from it, because the truth may lie in another direction, perhaps even the fashionable one.

If you've made up your mind to test a theory, or you want to explain some idea, you should always decide to publish it whichever way it comes out. If we only publish results of a certain kind, we can make the argument look good. We must publish both kinds of results.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.

Richard Feynman.

-

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

Richard Feynman.

-

The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty.

Richard Feynman.

-

Some people say, "How can you live without knowing?" I do not know what they mean. I always live without knowing. That is easy. How you get to know is what I want to know.

Richard Feynman.

-

I don't know anything, but I do know that everything is interesting if you go into it deeply enough.

Richard Feynman.

-

So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies . . . publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.

William Osler.

-

The greater the ignorance the greater the dogmatism.

William Osler.

-

The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.

William Osler.

-

One of the first duties of the physician is to educate the masses not to take medicine.

William Osler.

-

In the fields of observation chance favors only the prepared mind.

Louis Pasteur.

-

Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.

Louis Pasteur.

-

Not far from the invention of fire must rank the invention of doubt.

Thomas Henry Huxley.

-

The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.

Thomas Henry Huxley.

-

The foundation of morality is to have done, once and for all, with lying; to give up pretending to believe that for which there is no evidence, and repeating unintelligible propositions about things beyond the possibilities of knowledge.

Thomas Henry Huxley.

-

My business is to teach my aspirations to conform themselves to fact, not to try and make facts harmonise with my aspirations.

Thomas Henry Huxley.

-

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.

Tom Stoppard

-

All men can be criminals, if tempted; all men can be heroes, if inspired.

G. K. Chesterton

-

There is no such thing on earth as an uninteresting subject; the only thing that can exist is an uninterested person.

G. K. Chesterton

-

Good taste, the last and vilest of human superstitions, has succeeded in silencing us where all the rest have failed.

G. K. Chesterton

-

Men become superstitious, not because they have too much imagination, but because they are not aware that they have any.

George Santayana

-

If we are uncritical we shall always find what we want: we shall look for, and find, confirmations, and we shall look away from, and not see, whatever might be dangerous to our pet theories. In this way it is only too easy to obtain what appears to be overwhelming evidence in favor of a theory which, if approached critically, would have been refuted.

Karl Popper

-

It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

Upton Sinclair

-

Freedom is what you do with what's been done to you.

Jean-Paul Sartre

-

Where goods do not cross frontiers, armies will.

Frédéric Bastiat

-

The ultimate result of shielding men from the effects of folly is to ﬁll the world with fools.

Herbert Spencer

-

Political language — and with variations this is true of all political parties, from Conservatives to Anarchists — is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

George Orwell

-

Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.

John Adams

-

We're not presuming the answers before we ask the questions.

Lawrence Krauss explaining how science works

-

Malo Periculosam Libertatem Quam Quietum Servitium.

Better freedom with danger than peace with slavery.

-

Whatever inspiration is, it's born from a continuous "I don't know."

Wislawa Szymborska

-

All sorts of torturers, dictators, fanatics, and demagogues struggling for power by way of a few loudly shouted slogans also enjoy their jobs, and they too perform their duties with inventive fervor.

Well, yes, but they "know." They know, and whatever they know is enough for them once and for all.

They don't want to find out about anything else, since that might diminish their arguments' force.

Wislawa Szymborska.

-

Theory helps us to bear our ignorance of fact.

George Santayana

-

Miracles are propitious accidents, the natural causes of which are too complicated to be readily understood.

George Santayana.

-

Fanaticism consists in redoubling your efforts when you have forgotten your aim.

George Santayana

-

There is a fundamental difference between religion,

which is based on authority,

and science,

which is based on observation and reason.

Science will win because it works.

Stephen Hawking.

-

The truth, indeed, is something that mankind, for some mysterious reason, instinctively dislikes. Every man who tries to tell it is unpopular, and even when, by the sheer strength of his case, he prevails, he is put down as a scoundrel.

H.L. Mencken.

-

It is the natural tendency of the ignorant to believe what is not true. In order to overcome that tendency it is not sufficient to exhibit the true; it is also necessary to expose and denounce the false.

I am attempting to make it easier, when I use footnotes, to navigate to the information in a footnote, look at the information, and return to where you were before you clicked on the footnote. If you click on the number of a footnote in the text[1] <- click on the bracketed and underlined number - in this case [1], it will bring the footnote to the top of the screen.

[1] If you click on the bracketed and underlined number of a footnote in footnote section, the [1] at the beginning of this paragraph, it will take you to where you clicked on the footnote in the text, with the footnote along the top of the screen. [To top of footnotes]

If you wish to modify the size of the text, you can press the CTRL key and roll the mouse wheel forward or back, or you can press the CTRL key and the + or - keys to make text larger or smaller. Another way is to adjust the font in your browser controls.

This is a mostly medical blog, so here is the HIPAA incantation to ward off evil whiny HIPAA-obsessed spirits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is generally misrepresented by those in health care, but there are no violations of HIPAA here. There are some patients I could not discuss without changing details, so details may be omitted, or changed. That may decrease the dramatic effect of some of what I write, but patients are entitled to their privacy and have been since before HIPAA became the ignorant administrators' justification for imitating a two year old yelling NO!

I am not dispensing medical advice. If you get your medical advice off of a blog, instead of consulting a physician (such as your medical director), you probably should not be treating anyone, not even yourself. I could include your dog, but that would suggest that veterinarians do not provide excellent care. The veterinarians I know take pride in the care they deliver and deliver excellent care, more so than many people I know in EMS.

I do point you to research to support what I write, but you still need to make sure that you have the authorization of your medical director before changing any of your treatments. If your medical director does not agree, you can point to the research I write about. Most doctors do understand research, they just have trouble keeping up with the amount of research that is produced.

What I write does not change your protocols. If you do not like a protocol, take it up with the medical director. I have several inadequate protocols, too. I call medical command and attempt to persuade the physician that what I am requesting is in the best interest of the patient. It is rare that I am turned down, but the dose is often inadequate. I call back before I need more, so the patient does not have to put up with the On Line Medical Command delay in treatment. Health care providers should be anticipating where the care of the patient is headed - both for good and for bad.

I do not have any connection to the products I mention, other than using them and being satisfied, dissatisfied, or some combination of the two. If I have any potential conflict of interest, I will mention it clearly.

If I write about a book by an author I know, I will encourage you to buy the book from the author's web site. This means that any money goes to the author (or to where the author wants the money to go, such as a charity) and you have an opportunity to sample the author's writing for free on the author's blog before buying the book.

I may be blunt, but I do not intend it personally. There are few mistakes that can be made that I have not made. I continue to try not to be stupid; you may conclude that I fail.

I welcome any relevant comments and much that is not relevant. I reserve the right to delete any inappropriate comments. I decide what is appropriate based on my own nebulous standards. Criticism of ideas is expected. Criticism of writing style is appreciated.

I avoid obscenity because I believe that the English language provides enough opportunities for creativity that resorting to the words that may not be said on TV (and a growing group of words that may) is unnecessary. I may quote something that contains some of these words, or I may link to something that does, but that is as bad as I expect to be with these words.

On the other hand, you may feel that the ideas I present are offensive. My aim is to encourage thought, dialogue, and creativity - not to tell you everything is OK. You may leave this blog at any time and bury your mind in comfortable, familiar ideas.

If you feel that the ideas I present are not challenging, please encourage me to address whatever you feel I do not adequately address.